The 2001 Bethesda System: terminology for reporting results of cervical cytology

Diane Solomon, MD; Diane Davey, MD; Robert Kurman, MD; Ann Moriarty, MD; Dennis O'Connor, MD; Marianne Prey, MD; Stephen Raab, MD; Mark Sherman, MD; David Wilbur, MD; Thomas Wright, Jr, MD; Nancy Young, MD; for the Forum Group Members and the Bethesda 2001 Workshop

JAMA. 2002;287:2114-2119.

Objectives  The Bethesda 2001 Workshop was convened to evaluate and update the 1991 Bethesda System terminology for reporting the results of cervical cytology. A primary objective was to develop a new approach to broaden participation in the consensus process.

Participants  Forum groups composed of 6 to 10 individuals were responsible for developing recommendations for discussion at the workshop. Each forum group included at least 1 cytopathologist, cytotechnologist, clinician, and international representative to ensure a broad range of views and interests. More than 400 cytopathologists, cytotechnologists, histopathologists, family practitioners, gynecologists, public health physicians, epidemiologists, patient advocates, and attorneys participated in the workshop, which was convened by the National Cancer Institute and cosponsored by 44 professional societies. More than 20 countries were represented.

Evidence  Literature review, expert opinion, and input from an Internet bulletin board were all considered in developing recommendations. The strength of evidence of the scientific data was considered of paramount importance.

Consensus Process  Bethesda 2001 was a year-long iterative review process. An Internet bulletin board was used for discussion of issues and drafts of recommendations. More than 1000 comments were posted to the bulletin board over the course of 6 months. The Bethesda Workshop, held April 30-May 2, 2001, was open to the public. Postworkshop recommendations were posted on the bulletin board for a last round of critical review prior to finalizing the terminology.

Conclusions  Bethesda 2001 was developed with broad participation in the consensus process. The 2001 Bethesda System terminology reflects important advances in biological understanding of cervical neoplasia and cervical screening technology.

     

Infantile haemangioma: Part I. Pathophysiology,epidemiology, clinical features,life cycle and associated structural abnormalities

Infantile haemangioma (IH) is the most common tumour of infancy. Its typical natural history is characterized by an early rapid growth following birth and a slow spontaneous regression phase within a period of 3 to 7 years. The exact aetiopathogeny underlying IH is still to be fully understood, but the role of fetal hypoxic stress is strongly suggested as a triggering signal in epidemiological studies. IH are composed of a complex mixture of cells including multipotent stem cells, a majority of immature endothelial cells, pericytes, dendritic cells and in the late stage, adipocytes. Most of IH are nodular and are not associated with malformations. However, in some cases, IH referred to as segmental may be associated with developmental abnormalities such as PHACES and PELVIS/SACRAL syndromes.     

Detection of high grade squamous intraepithelial lesions and tumors using the AutoPap System: results of a primary screening clinical trial

BACKGROUND: The AutoPap System for the initial screening and quality control of conventional cervical cytology slides previously has shown superior performance for the detection of abnormal slides of low grade squamous intraepithelial lesions and above. This report presents data regarding the important category of high grade squamous intraepithelial lesions and above (HSIL+). METHODS: All slides were run through a Current Practice (CP) arm of manual screening with 10% random quality control followed by an AutoPap (AP) arm of device initial screening with approximately 25% of slides receiving no further review; 75% received a manual rescreen with AP ranking and QC rescreening of 15% of the top ranking negative manual screen slides was performed. Detection performance for truth-determined HSIL+ cases was compared between the two study arms. Available follow-up biopsy results were correlated for cases determined to be HSIL+. RESULTS: Of 25,124 analyzed slides, 70 slides had truth-determination at the HSIL+ level (67 HSILs, 1 adenocarcinoma in situ, and 2 invasive tumors). The AP arm identified 68 of 70 cases (including both invasive tumors). Neither false-negative HSIL+ was found in the 25% "No Further Review" population. The CP arm identified 65 of 70 cases (missing both invasive tumors). The results showed statistical equivalence between the two arms (P = 0.0129). Biopsy follow-up was available in 27 of 70 HSIL+ cases identified by AP and showed abnormality at some level in 100% of cases. CONCLUSIONS: The AP arm was statistically equivalent and showed numeric superiority to the CP arm for the category of HSIL+. Follow-up data confirmed the true-positive nature of these findings. These results are significant because any overall improvement in the performance of an initial screening device must be paralleled by at least equivalence in the clinically important subset category of HSIL+. Cancer (Cancer Cytopathol) Copyright 1999 American Cancer Society.     

Critical role of Aquaporin-1 and telocytes in infantile hemangioma response to propranolol beta blockade

Propranolol, a nonselective β-adrenergic receptor (ADRB) antagonist, is the first-line therapy for severe infantile hemangiomas (IH). Since the incidental discovery of propranolol efficacy in IH, preclinical and clinical investigations have shown evidence of adjuvant propranolol response in some malignant tumors. However, the mechanism for propranolol antitumor effect is still largely unknown, owing to the absence of a tumor model responsive to propranolol at nontoxic concentrations. Immunodeficient mice engrafted with different human tumor cell lines were treated with anti-VEGF bevacizumab to create a model sensitive to propranolol. Proteomics analysis was used to reveal propranolol-mediated protein alteration correlating with tumor growth inhibition, and Aquaporin-1 (AQP1), a water channel modulated in tumor cell migration and invasion, was identified. IH tissues and cells were then functionally investigated. Our functional protein association networks analysis and knockdown of ADRB2 and AQP1 indicated that propranolol treatment and AQP1 down-regulation trigger the same pathway, suggesting that AQP1 is a major driver of beta-blocker antitumor response. Examining AQP1 in human hemangioma samples, we found it exclusively in a perivascular layer, so far unrecognized in IH, made of telocytes (TCs). Functional in vitro studies showed that AQP1-positive TCs play a critical role in IH response to propranolol and that modulation of AQP1 in IH-TC by propranolol or shAQP1 decreases capillary-like tube formation in a Matrigel-based angiogenesis assay. We conclude that IH sensitivity to propranolol may rely, at least in part, on a cross talk between lesional vascular cells and stromal TCs.

Infantile hemangioma (IH), the most frequent tumor of infancy affecting 1 to 5 out of 100 newborns, is a noncongenital benign vascular tumor. Although most IHs are small, inconsequential, and regress spontaneously in many cases, medical treatment is needed in at least 15% of cases. The current first-line therapy for severe IH is systemic propranolol, a nonselective β-adrenergic receptor (ADRB) antagonist (1). Three subtypes of ADRBs (ADRB1, ADRB2, and ADRB3), which are coded by three distinct genes, belong to the superfamily of G protein–coupled receptors. They are characterized by a pocket containing binding sites for agonists (e.g., adrenaline and noradrenaline) and competitive antagonists (e.g., propranolol and timolol) (2). Although a role for ADRB in cancer progression was suggested long ago (3), our serendipitous observation of the efficacy of propranolol in treating IH (4) prompted many researchers to explore the anticancer properties of β-blockers.Although the therapeutic effect of propranolol is thought to be due to its ability to affect vasoconstriction, endothelial cell (EC) apoptosis, and/or inhibition of angiogenesis by modulating vascular endothelial growth factors (5, 6), the precise mechanism of its action is still under debate and largely unknown. Propranolol has been shown to have a growth inhibitory effect as a monotherapy on hemangioma cells in vitro (7–9). Nevertheless, growth inhibition was observed at doses 100- to 1,000-times higher than the plasmatic dose measured in treated IH patients (i.e., never above 0.5 µM) (10). It is then difficult to make the assumption that the effect of propranolol in IH can be mimicked and studied with such unrealistic doses. Indeed, the absence of an in vivo IH model that has shown a tumor growth inhibition induced by propranolol as well as difficulties in accessing IH patient samples before and after treatment have jointly hindered the quest to reveal its mechanism of action. Although several attempts have been made to create an in vivo IH model, a convincing antitumor effect of propranolol is still lacking (11–15). Of note, Lee et al. showed an effect of propranolol on vascular volume in a model of hemangioma cell–formed vessels in mice but without studying the effect on tumor growth (15). Considering this global effort and given the potential interest to identify a biomarker of malignant tumors sensitive to propranolol, we decided to explore the antitumor effect of propranolol in different tumor types in vivo. Retrospective clinical studies have shown that β-blocker use for hypertension is associated with improved cancer-specific survival compared with patients using other types of antihypertensive medications. For instance, a beneficial effect on survival was seen in breast cancer patients receiving the nonselective β-blocker propranolol but not with the β-1 antagonist atenolol (16). Additional studies showed a benefit of β-blocker use in patients with colorectal (17, 18) and pancreatic cancer (19). A prospective nonrandomized study of propranolol in the adjuvant setting for resected melanoma found an 80% reduction in melanoma recurrence (20). However, prospective clinical evidence supporting a role for propranolol in cancer treatment or prevention is limited. It is unlikely that beta blockade becomes an anticancer drug as a monotherapy, but combination therapy seems more promising (21). In this work, our hypothesis was that the antitumor effect of propranolol in malignant tumors was related to some common feature with the IH microenvironment. Since the increase of hypoxia-induced mediators has been shown in children with hemangioma (22, 23), we speculated that a hypoxic microenvironment could trigger the propranolol antitumor effect. We therefore chose a model of human malignant tumor cells xenografted in immunocompromised mice with continuous treatment of anti–vascular endothelial growth factor-(VEGF-A) bevacizumab (Avastin), hereafter abbreviated as Bev, in order to obtain a hypoxic tumor model (24). Tumor hypoxia induced by sunitinib and bevacizumab has already been used in mouse models in order to study specific drug sensitivity induced by up-regulation of HIF-1-α hypoxia (25). Sunitinib has also been used to assess propranolol antitumor efficacy in a melanoma model (26); nonetheless, bevacizumab is a more specific antiangiogenic drug than sunitinib.Using human malignant cell lines xenografted into immunodeficient mice as a model, we show in this study that propranolol induced the down-regulation of aquaporin-1 (AQP1), a transmembrane protein forming a channel for water and small solutes (27–30), and has a very pronounced effect on tumor growth in our mouse model (31–34). Looking for AQP1 expression in IH, we describe a special peripheral vascular layer made of dendritic cells named telocytes (TCs) with highly specific expression of AQP1, suggesting a key role in the exquisite sensitivity of IH to propranolol, which was verified in vitro with patients’ cells.